PATIENT:

adjective: bearing pains or trials calmly or without complaint

noun: an individual awaiting or under medical care and treatment

from Merriam-Webster Online

Photo by frances 1972

Nobody likes to wait.

But, like it or not, the world is filled with situations where we commonly have to do so. Sometimes the waits are excusable and even predictable, and other times they are not. At most doctors’ offices, one can expect to wait to varying degrees beyond their scheduled appointment time. It’s predictable. But is it excusable?

As a doctor who has done plenty of outpatient work, I am well aware of both sides of this coin.

Patients very understandably assert that their time is valuable, too. They often see it as arrogant on a doctor’s part when they are made to wait. Disrespected is how these patients usually feel. “How dare that doctor believe that his time is more important than mine!” is the mantra.

While I can sympathize with this viewpoint, the situation is more complicated than one might assume. And it’s not usually personal or intentional even though it may feel that way to patients.

Some of the primary reasons that doctors run behind schedule include emergencies, patients’ visits taking longer than anticipated, and patients (ironically) arriving late to their appointments. Most of these situations are beyond physicians’ control. Doctors also must return phone calls, speak with pharmacists, and fill out many forms.

I suspect that many patients do not realize that these issues can be frustrating and stressful for doctors, too. Speaking for myself, I am a conscientious person. It bothers me to be running behind. I truly don’t want to inconvenience anyone or waste their time.

So I do try diligently to stay as close to on-schedule as I can. But if I’m to be a competent, conscientious physician, I absolutely cannot make this my first priority. Avoiding or trying to repair train wrecks is more important than the train schedule.

If my first priority is the clock, then I will be more likely to appear rushed or insensitive, not listen carefully, miss important clinical findings, or maybe minimize the importance of something that warrants attention. Patients matter, and their clinical needs, which are often unpredictable, must come first.

Since so much is beyond doctors’ control, should we all just give up and not worry about staying on schedule?

Absolutely not. There are some ways that physicians can improve timeliness. For example, there are methods for improving efficiency and workflow in clinics.  American Medical News recently published an article to help physicians reduce wait times by addressing such issues. Doctors’ offices also can hire consultants to help them with the task.

What can patients do?

Arrive on-time (I know that sounds like a double standard, but one late patient can result in many more patients having to wait). Be organized–come with a concise list of questions. Be realistic–do not expect a doctor to be able to address several issues in one brief follow-up appointment. Finally, remember that your doctor may be behind because he needed to spend extra time with a patient in need. Next time it might be you–be glad if your doctor is willing to take the extra time when it really matters.

What do you think about this issue? In particular I’d really like to know how long you believe is a reasonable wait in a doctor’s office.

I’ve previously written about the many challenges of practicing medicine in correctional settings. But if there are so many cons (pun intended), why should anyone consider such a career?

Well, there are many benefits to it as well. If you are a psychiatrist or primary care physician and are either looking for a change or just starting your career, you may want to consider correctional medicine.

Although I’ve done correctional work for quite a few years, my experience has been limited to one geographical area of the country. I contacted correctional healthcare recruiter, Vikkie Schill, from MHM Services, Inc., to help me to convey accurate information about this topic. I want to take this opportunity to thank her for her input. I have no relationship either with Ms. Schill or with MHM Services, Inc.

Here are my top 5 reasons to consider a career in correctional medicine:

1. The patients: Believe it or not, I enjoy working with inmates. Most of my prison patients are polite and genuinely appreciative of my efforts to help them. Sure, if you work in corrections you’ll have to deal with some drug-seeking behavior or other attempts to get you to provide special privileges, but these situations comprise a small minority of patient interactions.

The patient population also is quite diverse. Physicians can expect to see the full array of psychiatric and medical problems. You’ll need all of your professional skills to treat inmates, and you’ll also be treating an underserved population.

2. The hassle factor: Would you like to do what you were trained to do and focus on practicing medicine instead of dealing with other administrative, insurance, regulatory and business hassles? In corrections you can.

Yes, you’ll have to work within a formulary, but in most cases it should be one formulary and not several. You won’t be dealing with prior authorizations, denied claims, billing, collections, coding, paying for overhead, hiring staff, or (in most cases) purchasing your own malpractice insurance. You won’t have to phone-in prescriptions or return phone calls to patients, either. (Inmates communicate with their doctors by submitting written request slips. You will have to spend some time replying to those, but this a more efficient process than playing phone tag with patients.)

3. Getting paid: You will earn a salary or hourly wage. If you cannot see a patient because he refuses to meet with you or because security procedures interfere with your appointment schedule, you still will get paid.

Vikkie Schill informed me that in her company, which provides health care services for many correctional systems, physician salaries vary from state to state. In most cases they are comparable, and in certain cases higher, than in other practice settings. She also mentioned that for early career psychiatrists, MHM Services’ starting salaries tend to be more competitive than those of private practice or hospital settings.

4. Patients’ access to treatment: It is frustrating to treat seriously ill patients in the community and for various reasons have them not follow through with appointments or take needed medication. Since inmates do have a constitutional right to health care and reside in the structured setting of prison, these challenges are much reduced. Most patients do come to their medical/psychiatric appointments. Their medications are paid for, and adherence to prescribed medications is logged.

5. The structure and flexibility: The highly structured nature of prisons makes providing health care there more structured and predictable as well. Have you ever had the experience of having a waiting room full of patients (who have busy schedules, too) while you’re running way behind, the phone is ringing endlessly, and some emergency is happening? I have too. I’ve worked in that type of environment in the community. You will certainly be busy practicing correctional medicine, but you probably won’t find yourself multitasking as much. If there is an emergency, you will be more likely to be able to focus on it. Everything else can wait. If routine patients need to be rescheduled, it’s not a problem.

Many physician positions in corrections offer flexible work arrangements and hours. You can work part-time or full-time. (In my opinion, combining part-time corrections work with part-time non-corrections work is the best way to achieve more professional balance and reduce one’s risk of burnout.) Depending on where you work, you may have little to no on-call responsibilities. Typically there are no weekend hours. And, you probably won’t even be allowed to work on holidays.

So, are you curious about working in corrections? It’s not for everybody, but for some doctors, it’s a great option. Do you wonder if you’d be suited to correctional work? I previously wrote an article about the ideal traits of a correctional psychiatrist that may give you some ideas.

If you already practice medicine in corrections, please feel free to share your experiences and opinions.

I know an elderly psychiatrist who used to do some small-time farming. I was always impressed with how many things he could buy without his wife objecting. Many of the items he purchased could have been considered, depending on one’s viewpoint, “tools” or “toys” (power tools, trucks, old tractors, etc.). There seemed to be two reasons he was able to do so. First, he had a great strategy. Anytime he bought something for himself, he either bought the same thing for his wife or bought her something equivalent. If he bought a Grand Cherokee, she got one, too. It must have been expensive, but it probably helped him to avoid years of marital discord and ultimately Dr. Phil telling him to “get real.” The second reason he got away with buying so much stuff was, as he told me, because “the tool always creates the job.” He loved all of these toys, and he had a special knack for always proving how useful each of them was because he inevitably would find the “need” that the tool would fulfill.

Is the social media craze similar to my psychiatrist friend’s farm tools? Do some of us just love technology so much that Twitter, Facebook, blogs, and now Buzz are becoming perceived necessities to justify our professional use of them? Are they actually useful, or are we just afraid that we will miss something by not jumping on the bandwagon?

I recently read a primary care physician’s response to a blog post. He made the point that he does not use social media, not even e-mail, to communicate with patients because he does not have to. Regardless of what he does, his waiting room is always full of patients, and his mailbox is always bursting with new career opportunities.

He makes a good point. And, at some level, he is probably right. One could probably easily spend many more years practicing clinical primary care as Dr. Luddite and never run out of work.

But, is that approach short-sighted? I think it is.

The challenge for physicians, regardless of specialty, is that we are very busy and already overwhelmed with time-consuming, unreimbursed communications with patients. We are very hesitant to do what may seem like the opening of yet more lines of communication. Things may get so out of control that we’ll need to hire Dr. Phil to tell our patients to “get real.” And, of course, we don’t want to do that.

The other issue is that the practice of medicine is so damned over-regulated that unless you work in a mega-medical system, it is nearly impossible to be compliant with all of the detailed regulations that exist. It’s difficult enough to navigate around HIPAA violation mine-fields as it is. Who wants to bother thinking about where social media fits into the picture?

Busyness combined with fear and burdensome regulations stifle our creativity and innovation in medicine. I believe that social media will in some way become vital adjunctive tools that we will use in medical practice. And, we may as well face the fact that our patients will increasingly expect our participation. We may not know how it’s all going to work in the coming years, but I think that those who write off advances in technology as meaningless time-wasting fads will ultimately be left behind, probably on their rotary-dial phones, on hold, waiting to talk to Dr. Phil.

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I used to have a more “normal” job.

Early in my career I worked in a large medical center and hospital and rotated through a call schedule. I got called into the ER regularly. I covered the inpatient unit and performed consultations on the medical and surgical units. I did all of the typical work tasks associated with a traditional practice.

Then I left it all.

I started working half-time in correctional psychiatry. I have worked in various other less traditional settings to fill the other half of my schedule over the years, but most of it has been spent working with people with developmental disabilities.

My work life is very, very different from what it was. I like many aspects of it now, and I’ll write more about that some other time. But, I have mixed feelings about having a job that is, well…weird.

Psychiatrists face a great deal of prejudice and stigma regardless of practice setting. Just go to a party and tell people you don’t know that you’re a psychiatrist, and you’ll understand what I mean.

Add to being a psychiatrist the fact that one practices in prisons, and the stigma and lack of respect issues intensify.

For example, in a 2008 survey by the American Correctional Association that was designed to identify the barriers to the recruitment and retention of educators and various health professions, 83% of respondents indicated that “lack of occupational prestige” was a top reason that retaining psychiatrists in corrections was difficult.

On the one hand, some people are quite curious about my field. I believe that this interest stems from a genuine curiosity that many have about prisons. They are forbidden places, extraterrestrial worlds into which most people never enter. In fact, wanting to give others a glimpse into this exciting yet disturbing domain was one of the original reasons that I started this blog.

Unfortunately, for every person interested in or fascinated by my unusual career choice, there are many more who have a negative reaction.

It’s not uncommonly a socially awkward pause followed by a forced smile and a disingenuous, “Oh, that must be interesting” comment. Simultaneously their body language screams, “Quick exit!”

I believe that more people assume that correctional psychiatrists either must be very strange for choosing such a line of work, or else they assume that we’re incompetent wannabe doctors not capable of having “real” practices.

I’ve been told several times over the years by nurses that I “seem so normal” compared to some of the other psychiatrists with whom they’ve worked. I guess I am supposed to feel flattered by such comments, but it is annoying always to be in an uphill battle against stigma and normalcy. The most recent comment I heard from a nurse, and I believe she’s said this to me at least twice, is that every time she hears the country song, “God is great, beer is good, people are crazy,” she thinks of me. Gee, thanks. Just how I want to be remembered!

I don’t dwell on these negative reactions about correctional psychiatry, and on most days they don’t bother me. I do what I do because I really do like it, and that’s what matters. I also do it by choice and am free to leave it at any time. There are even advantages to having a job that is less popular.

But, I’d be lying if I didn’t admit that, especially on a bad day, a part of me still finds it frustrating and somewhat depressing to have spent 9 years in medical school, residency, and fellowship so that I can have a position that I like and believe to be important yet is undervalued, stigmatized, and is thought of by many as, well…weird.

Photo: Tim Pearce, Los Gatos

A few months ago I performed an inpatient consultation on a non-incarcerated patient. His psychiatric care was being managed by a neurologist in another community.

I was shocked and disappointed when his family informed me that the neurologist told them that if the patient sought a medical opinion elsewhere, the neurologist would no longer treat the patient.

Even on a bad day I cannot fathom exuding such arrogance and insecurity! Hopefully this doctor’s attitude about second opinions is the exception and not the rule among physicians. However, this situation sparked my curiosity about second opinions.

Throughout my career, I’ve often encouraged my patients to obtain second opinions, either when they have questioned my diagnoses or treatments or when I have given them serious diagnoses such as schizophrenia.

In other situations I have specifically arranged for them to see trusted colleagues for second opinions when I have been clinically perplexed or have needed another psychiatrist’s input for risk management purposes.

In correctional work it tends to occur more in the context of risk management. For example, if an inmate strongly disagrees with the treatment I am providing, having him see another psychiatrist lends credibility to my treatment and helps to protect me legally if he tries to initiate legal action.

Interestingly, regardless of treatment setting, I’ve never had a patient see another psychiatrist for a second opinion and decide not continue his or her treatment with me. I don’t think that the reason has anything to do with my having superior knowledge or treatment approaches. I would bet it is due to the fact that I honestly try to collaborate with patients, and I’m not afraid to say, “I don’t know.”

Until now, I really hadn’t thought much about if, when, and how often other physicians, regardless of specialty, request second opinions on their own patients.

If you are a physician, do you ever request second opinions on your own patients? Under what circumstances? Do you ever try to discourage patients from obtaining second opinions?

If you are a patient, have you had any experiences, positive or negative, with second opinions that you would like to share?